=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376079541
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYNN ADHC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2017
-----------------------------------------------------
Last Update Date | 05/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 307 UNION ST
-----------------------------------------------------
City | LYNN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01901-1314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-212-9145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 307 UNION ST
-----------------------------------------------------
City | LYNN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR
-----------------------------------------------------
Name | ALEX EYDINOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 781-254-6074
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------